Before I arrived at the Emergency Hospital at the end of Oct 2005, I had not known if the hospital was clean enough, the operating theater (O.T.) personnel and young trainee surgical staff dedicated enough, and the situation appropriate for SIGN to be a viable concern. After seeing the number of patients in traction, getting an idea of the type of trauma that presented to Emergency's OPD, working with the six young Afghan surgeons for couple weeks, and getting a feel for the way the O.T.s ran, I felt that we could well use the system during the remainder of my three month stay. Dr. Marco, a trauma surgeon and the medical coordinator of Emergency in Afghanistan, expressed his interest and received the go-ahead from Emergency's office in Milan to purchase a set of SIGN instruments. I was most concerned about the sustainability of the system since none of the Afghan doctors have had formal Orthopaedic training and though there was always international surgical staff present, I had no guarantees that they would be willing to learn the technique and carry on. Dr. Zirkle and Jeanne Dillner's unstinting support clenched the debate.

Emergency is an Italian NGO (non-governmental organization) that sets up surgical hospitals to treat the civilian victims of war -- primarily land mine, shell and blast injuries as well as general trauma. The other major aspect of Emergency's mission is training local doctors.

Before the SIGN instruments arrived in Kabul on 7 December 2005, the doctors studied the technique CD. We spent one Friday afternoon (our day off) going through the different instruments, learning the names of the instruments so we could communicate effectively, assembling the target arm and getting a sense of the SIGN feel with the slot finder.

Our first six patients came from the ranks of those in traction for femur fractures—those recently set up because their fractures were too distal to accept a K-nail or those who were going on to non-union. Our first attempts at distal locking went all too well. Remembering the struggles Dr. Toba and I had had in Lesotho where I had taken the SIGN system the year before, I couldn't believe that the slot finder fell so consistently and beautifully into the slot. I was happy, but also worried that if all the cases turned out to be so easy, we would never have the opportunity to learn how to sort out the situations in which the nail didn't line up. My worries were unfounded. We had enough troubles over the next 7 weeks such that the doctors learned all the techniques of salvaging an off-centered cortical drill hole to eventually line it up with the nail slots. In fact I was amazed at how rapidly they learned the steps to take and the equanimity they showed when things didn't go well.

Our seventh case was of an old man who had fallen from a height some 5-6 months before presentation to the hospital. He had healed the distal part of his segmental femur fracture, but the proximal fracture had gone onto nonunion. We obtained good alignment of the femur after a difficult time taking down the fibrous tissue around the non-union and added iliac bone graft. Though he will never become a community ambulator, he is able now to get around with assistance and a walking frame.

After about a month we were in the position of being able to take care of the trauma within a few days of its arrival. A case of comminuted proximal femur fracture with posterior dislocation of the hip and complex fracture of the posterior wall and roof of the acetabulum, undisplaced patella fracture, and head trauma was treated within hours of his arrival with a SIGN nail, which then allowed us to gain a concentric reduction of the hip, which we treated in tibial tubercle traction. Though we hadn't the expertise nor instruments to surgically take care of the pelvis fracture, SIGN allowed us to quickly stabilize the femur, which was the key to treating his other injuries.

At this time we also saw a number of non-unions of comminuted proximal femur fractures that were failures of non-operative treatment. I was intellectually aware of the potential of SIGN to empower surgeons who worked in situations where they previously had no good solutions, but for the first time the true feeling of the extent of this empowerment struck me personally.

When the SIGN instruments arrived at the beginning of Dec. we had two patients with very comminuted femur fractures in traction. I spent a lot of time looking at their 2 and 4 week old x-rays, debating whether to continue with the traction or fix them operatively. I was certain that they were far too difficult and felt that the traction was doing an adequate job in maintaining alignment and leg length and was sure they would heal with time. But they didn't. The lack of good clinical and radiographic callus in both patients forced my hand. These became our 13th and 14th cases and I was surprised by the ease of the surgery.

From the descriptions, you can see that the majority of the fractures we treated were femur fractures. They were almost all closed or grade one open occurring from road traffic accidents or falls. The majority of our tibial fractures were very comminuted grade IIIB or C open fractures from gun shot wounds or mine injuries and not suitable in our setting for I.M. nailing. The more simple tibial fractures were routinely treated with closed ruction and P.O.P.s. The two tibial fractures we tackled were an eleven month old non-union and the immediate nailing of a transverse tibial fracture at the same time as nailing of the ipsilateral grade one open femur fracture.

Within the last year another SIGN project was started in Afghanistan. Mazar-i-Sharif, the major city in Afghanistan north of the Hindu Kush is the 3rd largest city in the country with a relatively new university and medical school. I took four days off and flew to Mazar to visit with Dr. Homanyun Darmangar, a well-trained young orthopaedic surgeon. His situation is far more difficult than that of the Emergency Hospital in Kabul due to the lack of decent infrastructure and a paucity of supplies. We shared our thoughts about SIGN and discussed the problems of delivering orthopaedic care in such a poor country. His level-headed approach to the myriad health problems facing Afghanistan encouraged me. We both agreed that SIGN--not just the instruments, but the organization and philosophy that sustain it--will help solve some of these problems.